Pages Navigation Menu

The Professional Literature of Gender Dysphoria (1991)

The Professional Literature of Gender Dysphoria (1991)

Copyright 1991, 2013 by Dallas Denny

Source: Dallas Denny. (1991). The professional literature of gender dysphoria: I. A brief survey, with prescription. Distributed by American Educational Gender Information Service, Inc., Decatur, GA.

Photo: Psychologist Leslie Lothstein. Between 1977 and 1989 he wrote a handful of papers and a truly appalling book about FTM  transsexuals.


Much of my early work concerned the truly repressive medical model of transsexualism. This is but one of several discussions of the literature that was born of the medical model.


The Professional Literature of Gender Dysphoria

A Brief Survey, with Prescription

By Dallas Denny


This is the first of what I intend to be a series of papers discussing the scientific literature of gender dysphoria. In future articles I will describe in more detail specific papers, or classes of papers, but to start, I thought I would give an overview of published work.

In undertaking such a project, it is inevitable that I will slight someone; I apologize beforehand for any omissions or errors of fact.


Early Contributions

 There was not a systematic literature of crossdressing or transsexualism before 1952, when Christine Jorgensen made her debut in the newspapers. Among the most notable early work was that of Magnus Hirschfeld, who has been called a crossdresser by Leslie Lothstein (1983), and others, but, according to Vern Bullough (1991), was more likely simply gay. Hirschfeld coined the term transvestism, and wrote extensively on the subject in the early part of this century. His classic work Die Transvestiten has only recently been translated into English. Other early sexologists, including Richard von Krafft-Ebing, and Havelock Ellis (who introduced the term eonism).

Transsexualism was treated sporadically in the early literature, under various names. From our temporal vantage point, it is easy to look back at case reports and identify transsexual features in the patients, but transsexualism was a condition undiscovered, and transsexual people were generally considered to be homosexual or psychotic, or else lumped with crossdressers and considered sexually deviate.


Transsexualism after 1952

A number of early papers were of peripheral relevance to transsexualism, as they dealt with surgical construction of vaginas in women born without vaginas, reconstructions of male external genitalia in boys born without penises and in men with traumatically amputated genitalia, and hormonal therapy. There were case reports of “crossdressers” who seem, retrospectively, to have been transsexual, and even an early German report of sex reassignment surgery (Abraham, 1931), but the floodgates were opened in 1953, when Hamburger, Sturup, and Dahl-Iversen simultaneously published a paper in a Scandinavian medical journal and in The Journal of The American Medical Association, describing the hormonal, psychiatric, and surgical treatment of a patient whose identity they did not disclose, but who could have only been Christine Jorgensen. Responses and rebuttals sizzled and popped like firecrackers for several years, as the ethics and wisdom, and even the legality, of transsexual surgery were debated.

The 1950’s also saw important work from the laboratory of John Money at The Johns Hopkins University. Money and his colleagues (most notably the Hampsons and Anke Ehrhardt), in studying persons with intersexual (hermaphroditic) conditions, learned much about normal and abnormal development, and made the critical distinction between sex and gender. This work logically led to the study of transsexualism, eventually resulting in the opening of the first gender identity clinic in the United States, at Johns Hopkins University, in 1967; other clinics soon followed.

The 1960’s brought a variety of published reports, including early studies of outcomes of sex reassignment surgery (usually based on case reports), the etiology and incidence of transsexualism, and the characteristics of persons presenting for sex reassignment surgery. By the end of the decade, John Money, Robert Stoller, Richard Green, and others were publishing extensively.

What is generally considered to be the first textbook published on transsexualism was Harry Benjamin’s The Transsexual Phenomenon in 1966. Actually, Georgina Turtle’s Over the Sex Border. Change of Sex: A Comprehensive Study was the first, in 1963, although D.O. Cauldwell’s Transvestism: Men in Female Dress, published in 1956, included considerable discussion of transsexualism. The word transsexual had been first used in 1949 by Cauldwell, but it was Benjamin who popularized it.

In 1968, Robert Stoller published Sex and Gender, a monograph on transsexualism, (and he followed it with other books). Green and Money’s edited volume, Transsexualism and Sex Reassignment, which consisted primarily of papers which had previously appeared in the literature, appeared in 1969, shortly after the opening of the Gender Identity Clinic at Johns Hopkins University. Green’s monograph, Sexual Identity Conflict in Children and Adults, appeared in 1974.

As gender identity clinics sprang up throughout the United States in the late 1960’s and early 1970’s, the staff of the clinics began publishing in professional journals. Descriptions of surgical techniques began to appear, as did reports of the clinics’ methods of dealing with persons requesting sex reassignment. More outcome studies were published.

Although the knowledge base increased tremendously, the inexperience of the workers at many of the clinics resulted in the appearance of papers which did not contribute significantly to the literature, and were, in fact, detrimental to the treatment and welfare of transgendered persons. Many were, in fact, basically opportunistic, and demeaning and belittling depictions of transsexual persons abounded. I have discussed the reasons for this in another article, The Politics of Diagnosis and a Diagnosis of Politics, which appears in the third issue of Chrysalis Quarterly, a magazine published by The American Educational Gender Information Service.

The 1980’s saw the closing of the gender clinics, with the result that the papers which appeared were more likely to originate from persons with legitimate and abiding interest in transsexualism. The quality of the literature improved significantly. Surgical and hormonal treatments grew more sophisticated, and articles about female-to-male transsexual people began to appear in greater numbers. Theoretical articles divided those requesting sex reassignment into clinical types based on clinical experience, and terminology was refined; researchers began to speak about the gender dysphorias, rather than transsexualism per se. Proceedings of national and worldwide congresses on gender dysphoria began to be compiled and published.

The 1980’s brought more textbooks, including Lothstein’s (1983) unsensitive treatment of female-to-male transsexualism, an edited volume from the Clarke Institute of Psychiatry in Toronto (Steiner, 1985), and an Australian compilation with the same title as Green and Money’s 1969 Transsexualism and Sex Reassignment (Ross & Walters, 1986).

The 1990s promise a continuation of the stereotyping and tunnel vision which have continued to plague the professional literature. A recent (1990) edited textbook by Blanchard & Steiner was reviewed by Jennifer Usher in the third issue of Chrysalis Quarterly, who found them overly conservative in a number of areas. 1992 has brought us Brian Tully’s Accounting for Transsexualism and Transhomosexuality, which is largely a collection of quotations from the files of England’s Charing Cross Hospital. The Clarke’s treatment of transsexual people has been in my opinion largely unfeeling and needlessly antagonistic, and Tully’s book suggests that Charing Cross shares some of the Clarke’s problems.


Crossdressing after 1953

Studies of crossdressers are far less common than are studies of transsexual people. This is probably because fewer crossdressers come under the scrutiny of the medical establishment. Crossdressers typically keep their activities private, showing up on the doorsteps of the helping professionals only when they have legal or emotional problems, or on the relatively rare occasions when their infatuation with crossdressing leads them to think that they might be transsexual. There did seem to be a bootstrap effect, however, as increased attention on transsexualism after 1953 led to more papers on crossdressing.

In the 1960’s, several articles reported the use of behavioral attempts to “cure” crossdressing. The severity of the presenting symptoms, as described by the authors, do not, in my opinion as an applied behavior analyst, justify the extreme aversive measures which were often used for a behavior which is benign, and which was in fact sometimes not really a major problem in the life of the subjects, who were shocked and given noxious substances like apomorphine, which made them violently ill.

Buhrich & McConaghy, Vern Bullough, Prince & Bentler, and others did much-needed descriptive studies in the 1970’s. Bullough did historical analyses of both crossdressing and transsexualism. Some of these authors did comparisons of the characteristics of transsexual people and crossdressers.

The 1980’s saw increased attention paid to the partners of crossdressers, who had been previously neglected. Dr. George Brown has published significantly in this area.


Other Important Contributions

In 1979, Jon Meyer and Donna Reter published a controversial but influential paper, in which they concluded that there was “no objective advantage” to reassignment surgery. Their study had serious methodological flaws, and has been refuted by many authors, the latest and most comprehensive critique being that of Ray Blanchard and Peter Sheridan in 1990, who also reviewed earlier analyses of Meyer & Reter (1979).

Despite its problems, Meyer & Reter (1979) is arguably the work which has had the greatest impact on the treatment of transsexual people, for as a consequence of the press release which attended the paper, the Gender Identity Clinic at Johns Hopkins closed. Other clinics followed, with the ultimate result that there are no longer, to my knowledge, any university-affiliated gender clinics in the United States (the Stanford and Texas programs, although still existent, are no longer officially affiliated with universities. I am unsure about the Minnesota program). Meyer & Reter (1979) is still quoted widely by those who use it as if it were the absolute authority on outcome, rather than the seriously flawed study that it was.

There are many others important and influential papers. Walinder, Lundstrom, and others in Sweden did extensive follow-up on operated transsexual people. Barlow and his co-workers did two intriguing studies, in which they achieved apparent change of gender identity in apparent transsexual males by use of a behavioral treatment package that included aversives. Richard Green, Kenneth Zucker, and others conducted longitudinal studies of feminine boys, discovering that they were much more likely to have homosexual adjustments in adulthood than to be gender dysphoric. Robert Stoller, a psychoanalyst, described the family characteristics of “pretranssexual boys” in a series of articles in professional journals, and in his books. Leslie Lothstein published prolifically, seemingly specializing in identifying minority (aging, adolescent, black schizophrenic, drug-abusing, physically deformed) sub-groups of transsexual people. Ira Pauly, Donald Laub, Milton Edgerton, Jon Meyer, Walter Meyer, David Gilbert, and others have published descriptions of surgical techniques and its outcomes. Meyer & Hoopes (1974) coined the term “the gender dysphorias,” pointing out that requests for sex change (transsexualism) can result from any number of underlying conditions (the gender dysphorias).

In a series of papers, Person & Ovesey (1974a, 1974b) divided transsexual males into “primary” and “secondary” groups, and further divided the secondary group into heterosexual (crossdresser) and homosexual categories. Blanchard (1990) wrote of “homosexual” and “nonhomosexual” gender dysphorias, and of autogynephilic (loving the feminine self) transsexualism.

Two important events were the publication of the Standards of Care of the Harry Benjamin International Gender Dysphoria Association, Inc., in 1979, and the inclusion of transsexualism as a diagnostic category in The Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (DSM III) in 1980 (updated in 1987, in the DSM III-R). These standardized, respectively, treatment and diagnostic criteria of transsexualism.


Some Problems With the Literature

Despite tremendous advances and many well-written, methodologically sound papers, there is much to criticize in the literature. Studies tend to suffer from the usual problems of applied research. Numbers of subjects are small, and intervening conditions and variables are rarely controlled, or even identified. Studies have not been carried out under blind conditions (that is, with the data collectors being ignorant of the hypotheses of the research or assignment of subjects to treatment or control groups). Group studies are rare, and, when they do exist, have sometimes collapsed individual case studies rather than forming a true group. Authors of early outcome studies, in particular, were guilty of this; this resulted in the same subjects being used in various studies. There is rarely extensive follow-up of treatment (and transsexual people, rather than researchers, are still being blamed for this). Most studies have been retrospective (backwards-looking) rather than prospective. Longitudinal studies have been very rare. Group studies using controls are especially rare, and single-subject, repeated measures studies are almost nonexistent.

There are difficulties other than with reliability. Problems of validity have been rampant. Most studies have a clinical bias, viewing the transgendered individual in a specialized and highly artificial situation. This biases the subject population, as only those seeking “help” show up and are studied in conditions which are quite unlike those in which they normally function. Researchers, with the exception of Ann Bolin, have been for the most part blind to the way their own needs and prejudices influence the treatment setting, and have placed all the blame on their transgendered clientele.

The individual and vocational biases of authors tend to be reflected in their work. Psychoanalysts, for example, have been the most vocal opponents of surgical treatment of transgendered people (perhaps because they have contributed the least to understanding and treating them). Lack of specialized training programs in human sexuality in general and gender dysphoria in particular have doubtless had an impact on the quality of the research questions asked by researchers of all theoretical orientations.


A Prescription for the Future

Transsexual people are not particularly common, and are not particularly cooperative when they are denied their way—and most crossdressers never make it to the treatment setting. This makes the already considerable problem of doing group studies in applied settings even more difficult. Certainly, group studies are needed, but they must be more rigorous than those which have gone before. Poorly-designed studies were better than nothing when there was no literature of gender dysphoria, but now there is a literature of gender dysphoria. The time for sloppy work is past. Future studies must replicate, confirming or not confirming already existing studies, as well as breaking new ground. The definitive outcome study, for example, has yet to be done and replicated—and until that happens, no one will really know how effective the surgical treatment of transsexualism is.

Single-subject studies, using the methodology of applied behavior analysis, are quite as rigorous and scientifically convincing as group studies (some would say more so), and would be much easier to do—yet they remain rare. Systematic replication of such studies would build the knowledge base in a rapid manner, just as such studies quickly yielded a reliable and valid technology of controlling persons with severe behavioral pathology. More should be done.

The publication, in 1978, of Kessler & McKenna’s Gender: An Ethnomethodological Approach, and Anne Bolin’s In Search of Eve: Transsexual Rites of Passage, a decade later, were of great import, for they had fresh (and much-needed) viewpoints that have gone unnoticed, or at least largely uncommented on, in the clinical literature. Kessler & McKenna’s theory of gender drew heavily upon their observations of transsexual persons. Both they and Bolin studied transsexual people in context, in their natural settings, rather than in the highly artificial setting of a physician’s office or a gender clinic. Bolin, in no uncertain terms, pointed out the major flaw in the literature—its almost exclusive reliance on clinical reports.

William Verplanck, who was one of my professors when I was in a graduate program in psychology at the University of Tennessee, pointed out in his seminars that for centuries biologists observed and collected and categorized their subjects. Only after a rigorous period of classification did they start in any great measure to theorize. Psychologists, on the other hand, began to theorize without bothering to assemble such a knowledge base. Consequently, biological theories such as Charles Darwin’s and Alfred Russel Wallace’s theory of natural selection have withstood the test of time, while entire schools of psychology (for example the Hullian) have withered and disappeared, leaving no legacy.

Researchers in the field of gender dysphoria should follow in the steps of the biologists and take the time to learn what transsexual people are like before soaring off into the delirious heights of theory. We should avoid the bad precedents of mainstream American psychology. If we do so, we will build something that will endure. If we do not, then our work will be forgotten.



 Abraham, F. (1931). Genitalumwandlung an zwei maennlichen transvestiten (Genital alteration in two male transvestites). Zeitschrift Sexualwissenschaft, 18, 223-226.

 American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders, 3rd. ed. Washington, D.C.: American Psychiatric Association.

 American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders, 3rd. ed., revised. Washington, D.C.: American Psychiatric Association.

 Benjamin, H. (1966). The transsexual phenomenon.New York: Julian Press.

 Blanchard, R. (1989). The concept of autogynephilia and the typology of male gender dysphoria. Journal of Nervous and Mental Disease, 177(10), 616-623.

 Blanchard, R., & Sheridan, P. (1990). Gender reorientation and psychosocial adjustment. In R. Blanchard & B. Steiner (Eds.), Clinical management of gender identity disorders in children and adults.Washington, D.C.: American Psychiatric Press.

 Blanchard, R., & Steiner, B. (Eds.). (1990). Clinical management of gender identity disorders in children and adults. Washington, D.C.: American Psychiatric Press.

 Bolin, A. (1988). In search of Eve: Transsexual rites of passage. South Hadley, MA: Bergin & Garvey Publishers, Inc.

 Bullough, V. (1991). Introduction. In M. Hirschfeld, Transvestites, (Michael A. Lombardi-Nash, translator). Buffalo, NY: Prometheus Books.

 Cauldwell, D.O. (1949). Psychopathia transsexualis. Sexology, 16, 274-280.

 Cauldwell, D.O. (1956). Transvestism: Men in female dress. New York: Sexology Corporation.

 Green, R. (1974). Sexual identity conflict in children and adults. New York: Basic Books, Inc.

 Green, R,, & Money, J. (Eds.) (1969). Transsexualism and sex reassignment. Baltimore: The Johns Hopkins University Press.

 Hamburger, C., Sturup, G.K., & Dahl-Iversen, E. (1953). Transvestism: Hormonal, psychiatric, and surgical treatment. Journal of the American Medical Association, 12(6), 391-396.

 Hamburger, C., Sturup, G.K., & Dahl-Iversen, E. (1953). Transvestism: Hormonal, psychiatric, and surgical treatment of a case. Nordisk Medium, 12(5), 844-848. (English abstract).

 Kessler, S.J., & McKenna, W. (1978). Gender: An ethnomethodological approach. New York: John Wiley & Sons.

 Lothstein, L. (1983). Female-to-male transsexualism: Historical, clinical and theoretical issues. Boston: Routledge & Kegan Paul.

 Meyer, J.K., & Hoopes, J.E. (1974). The gender dysphoria syndromes: A position statement on so-called transsexualism. Plastic and Reconstructive Surgery, 54(4), 444-451.

 Meyer, J.K., & Reter, D. (1979). Sex reassignment: Follow-up. Archives of General Psychiatry, 36(9), 1010-1015.

 Person E., & Ovesey, L. (1974a). The transsexual syndrome in males: I. Primary transsexualism. American Journal of Psychotherapy, 28, 4-20.

Person, E., & Ovesey, L. (1974b). The transsexual syndrome in males: II. Secondary transsexualism. American Journal of Psychotherapy, 28, 174-193.

 Steiner, B. (Ed.) (1985). Gender dysphoria: Development, research, management. New York: Plenum Press.

 Stoller, R.J. (1968). Sex and gender: On the development of masculinity and femininity, Vol. 1. New York: Science House.

Tully, B. (1992). Accounting for transsexualism and transhomosexuality.London: Whiting & Birch.

Turtle, G. (1963). Over the sex border. Change of sex: A comprehensive study.London: V. Gollancz, Ltd.

 Walters, W.A.W., & Ross, M.W. (1986). Transsexualism and sex reassignment.New York: OxfordUniversity Press.